July 12, 2009

Hospitals on readmission rates

The decision to publish hospitals' readmission rates is controversial.

Why should medical centers be held accountable for what happens to patients who walk out through their doors, several hospital executives ask. What if these patients decide not to take their medication or schedule a follow up visit with the doctor? Why should this reflect poorly on a medical center?

"This is a new frontier," acknowledged Dr. Mark Williams, co-author of a recent study on hospital readmissions published by the New England Journal of Medicine and chief of the division of hospital medicine at Northwestern's Feinberg School of Medicine.

On the one hand, it's important to educate patients about what to expect and connect them with useful resources before they leave the hospital, Williams said. Hospitals have devoted insufficient resources to careful discharge planning, leaving too many patients to their own devices, he noted.

On the other hand, it's important to ensure that patients who need to return to hospitals have the opportunity to do so, without facing new hurdles. "You have to ask, if we push readmissions down, will mortality go up?," William said. "We don't have an answer."

In many ways, he believes new Medicare data on hospital readmissions will be more useful to hospitals than it will be to patients. Hospitals haven't had this information before, especially information about which of their patients are admitted to other medical centers.

At Northwestern Memorial Hospital, for instance, a number of patients who are referred for specialized services -- for instance, treatments for heart failure -- go home to their communities where they are managed by their personal doctors.

"It's fair to ask, is it Northwestern's responsibility" if these patients receive less than optimal care in their communities?," Williams said. "This is a community care issue, not just a hospital issue."

Yet still, Williams believes it's important to focus on readmissions. "What this will do is drive us to improve the continuum of care" and that will be of wide-ranging benefit, he said. Hospitals need to do a better of job of helping patients making the transition back home and certainly the financial incentives that drive hospitals need to be changed, he explained.

"Currently, our health care system is paid to do things for patients but not to prevent bad things from happening," Williams said. Whatever new incentives are put in place should support care management across health care settings and shouldn't penalize hospitals that care for sickest, most complex, and poorest patients, he added.

Here are some comments from other hospitals who I contacted for my Sunday article on hospital readmissions and new data published by Medicare on its Hospital Compare Web site:

The Carle Foundation Hospital sent a statement from Mike Billimack, vice president of marketing and strategic planning. The Urbana hospital had a higher-than-average readmission rate for seniors with heart attacks.

"We continually look into the data for patients discharged from our hospital after AMI [acute myocardial infarction) and subsequently readmitted. Unfortunately, the (Hospital Compare) performance report includes patients discharged from Carle Foundation Hospital and readmitted to any other hospital for any reason (except stent placements and [coronary artery bypass] procedures). We do not have access to data for those patients admitted elsewhere. Therefore, the data is somewhat misleading."

It's true that the Medicare data includes readmissions to any hospital -- not just the hospital where the patient was originally treated. But hospitals like Carle have the opportunity to learn from Medicare where their patients are being readmitted and to initiate conversations with those institutions about how care for patient can be improved, said Dr. Stephen Jencks, a former top official with Medicare responsible for quality improvement.

Billimack also said that Carle ranked highly on other measures of performance for heart attack patients. It's important to acknowledge this and note that readmissions data doesn't tell the whole story.

Arnie Kimmel, chief executive officer of MetroSouth Medical Center in Blue Island, noted that the hospital, formerly known as St. Francis, is under new ownership. The 36 months of Medicare data only reflect eight months of the hospital's operation under new management, he said.

"Not all of the responsibility is the hospital's," he said, referring to why patients are readmitted within 30 days of discharge. "A significant part of the reason we have to attribute to [patients] lack of compliance" with medical recommendations. While the hospital is analyzing its criteria for admission through the emergency room, Kimmel said, he doesn't think it needs to make any other changes.

Kimmel observed that death rates for MetroSouth patients were well below the national average in the most recent period reported; a check of the Hospital Compare Web site confirmed this. Overall, he appeared to dismiss the signifiance of the readmissions data.

Ingalls Hospital in Harvey made available Linda Ambrosecchia, director of quality assurance, infection control and patient safety to discuss its higher-than-average readmissions rate for seniors with pneumonia. "We find a disconnect in the (Medicare measurements)," she said. The death rate for Medicare patients at the hospital is lower than the national average yet its readmission rate for pneumonia patients is higher, she observed.

Ingalls has been reviewing its readmissions for pneumonia and the trend line is moving downward. "In the last year, our rate was at the national average," Ambrosecchia said. She noted that the senior population Ingalls serves tends to be lower income and have multiple chronic conditions. "Some patients may not have basic resources to support their care at home," she said.

Advocate Health Care played up the good news -- lower-than-expected death rates for seniors at six of its hospitals -- in a statement. Regarding lower than-average readmissions rates for seven hospitals, the system down-played the significance of the data on the second page of a press release:

"Advocate continues to address opportunities to reduce readmission rates. The newly released data includes cases from up to four years ago, so the numbers do not capture improvements that are being made on an ongoing basis," said Dr. Lee Sacks, chief medical officer. "Also, the [Medicare] readmission rate is calculated without taking into consideration why the patient is being readmitted, if the patient followed the post-acute care plan and other factors not related to the quality of hospital care during an intial admission."

Comments

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Hospital readmissions are without question one of the most troubling issues facing our health care system. Approximately one in five patients hospitalized for a cardiac condition is readmitted within 30 days. In 2004, hospital readmissions cost Medicare a staggering $17.4 billion.

The rash of hospital readmissions, however, is not without a cure. Research shows that many can be prevented. To address the problem, my colleagues and I at the American College of Cardiology recently announced our Hospital to Home (H2H) campaign – an effort to reduce preventable heart failure and coronary artery disease readmissions by 20 percent over the next three years.

Rather than leave patients to their own devices, as Dr. Williams notes, the ACC will provide hospitals and practices with evidence-based strategies to improve the continuum of care. Whether it’s adhering to medications or following up with doctors, these strategies will ensure patients are properly educated before being discharged from the hospital.

Check out my blog – The Lewin Report (lewinreport.acc.org) – to learn more about this exciting campaign, and everything the ACC is doing to make sure patients have a safe and healthy transition from the hospital to back home.

Many research studies have been done demonstrating the effectiveness of using telehealth solutions, such as provided by Philips Healthcare, to reduce readmission rates. One study showed that telehealth reduced readmissions of heart Failure patients by 72%.
Hospitals and health care systems should be investing in this low cost, high return technology to save the U.S. healthcare system billions of dollars.

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Getting the medical care you need isn't easy. Resources can be hard to find. Weighing the costs and benefits of proposed interventions can be difficult. Choosing a doctor or a hospital, negotiating with your insurer, staying on top of treatment trends, getting the best care possible -- all these can be nerve-wracking. This blog will bring you useful information, connect you with important resources and highlight the stories of other people like you.